Male Versus Female Hospitalists

If you have paid attention to the news, you picked up the study out in JAMA concerning how male versus female physicians deliver inpatient care.  Not just any inpatient docs, though, but hospitalists. The investigators were meticulous in their analysis of over a million Medicare beneficiaries and looked at readmit and mortality rates.  They examined various diagnoses and adjusted for the usual doctor and hospital characteristics.

Across the board, males took a drubbing and the NNT for both outcomes of interest hovered around 200 (0.5% absolute difference). Ashish Jha, one of the investigators and a leader in the study of hospital quality and safety (who really needs to speak at an SHM annual, incidentally) goes into more depth over at his blog:

Given our results, if male physicians had the same outcomes as female physicians, we’d have 32,000 fewer deaths in the Medicare population. That’s about how many people die in motor vehicle accidents every year. Second, imagine a new treatment that lowered 30-day mortality by about half a percentage point for hospitalized patients. Would that treatment get FDA approval for effectiveness? Yup. Would it quickly become widely adopted in the hospital wards as an important treatment we should be giving our patients?  Absolutely. So while the effect size is not huge, it’s certainly not trivial.

[…] Further, for those who worry about “confounding” – that we may be missing some key variable that explains the difference – I wonder what that might be? If there are key missing confounders, it would have to be big enough to explain our findings. We spent a lot of time on this – and couldn’t come up with anything that would be big enough to explain what we found.

Reactions will vary depending on your gender and prior beliefs, but I accept the findings (correlation, not causation here). Women tend to be somewhat more evidence-based and communicate more effectively. We know that much.

How do we learn more, however?  How do we tease out where males fall short—and is it practical or possible to intervene on?  Even if you studied demented or sedated ventilated ICU or floor patients where gender recognition would presumably not occur, docs still interact with family and staff.  Maybe that is where the good stuff happens. There are just too many moving parts.

Some have suggested an RCT is not possible—and they are right on logistical grounds.  But we test PCI versus CABG or sham versus actual surgeries using clinical equipoise as standard, so why not the sex of provider?  Feels weird, even icky, but in the name of science, it could be done. Maybe Bill Gates has a few spare nickels under his couch—because I doubt the NIH is going to fund this baby.

SHMs own Vineet Arora highlighted another point we cannot overlook in the Washington Post (the same issue gets cited in the study’s accompanying commentary):

What the study drove home for Arora, who works as a hospitalist, is that women are certainly not worse doctors than men — and they should be compensated equitably. A study published earlier this year found a $20,000 pay gap between male and female doctors after controlling for other factors, such as age, specialty and faculty rank, that might influence compensation.

She noted that female doctors, who are often being hired in their childbearing years, may face a subtle form of discrimination, in the worry that they will be less committed or that they will not work as hard when they have children.

“Having a female physician is an asset,” Arora said.

I am sure you will see this study in brief reviews and update publications and will get a dose at any 2017 hospital medicine meeting.   However, do yourself a favor and at least skim some of the links above.  Beyond the science, there is a lot under the hood of this paper and its findings to think about. Just imagine, someday we may have to go back to every RCT ever done and add “gender of doc” to the list of variables we adjust for.  I am not kidding.